Macquarie Pension Manager II Application Form - Collins, Patrick - 19122019 PDF

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Super and Pension Manager II

Application form
Macquarie Investment Management Limited ABN 66 002 867 003 AFSL 237 492 RSEL L0001281.
Macquarie Superannuation Plan ABN 65 508 799 106 RSE R1004496.
Do not use this form unless it is attached to or accompanying the PDS dated 23 November 2019. 11/19
• Refer to the checklist on pages 1 and 2 of this application booklet for help with how to complete this application.
• Please use black ink and print in CAPITAL LETTERS. Mark boxes with an (X) where applicable.
Superannuation applicants u complete 1 to 13, then 18

Pension applicants u complete 1 to 9, then 14 to 18 including all original documents (where required)
A
Financial adviser use only
You must be a registered financial adviser to use this service.
Please note: we cannot process this application if the dealer code and adviser code are incomplete.
Dealer name: Australian Financial Planning Group Dealer code: 7959

Adviser name: Samantha Loveder Adviser code: AFPGSL

For more information regarding this application form please contact my assistant/support staff
Assistant/support name:
Contact number: 0282687000 Email: admin@afpg.com.au
1
Identification required (mandatory)
Accounts being established for a minor require the parent or guardian, rather than the child, to supply identification where
required. Additional documents may be required in some circumstances. We reserve the right to vary these requirements.
Did you hold an existing Macquarie account on 12 December 2007 which is still open?
Yes u continue to section 2
No, you are required, under the AML/CTF Act 2006, to supply identification by either:
• having your adviser complete the FSC/FPA Identification form – for Individuals & Sole Traders (on page 17) and verify the
identification documents specified there, or
• sending us a completed Individual Identity Verification form, available at macquarie.com.au/idforms, and either
– presenting supporting identification documentation as outlined on the form to an Australia Post office or Macquarie office,
where the form can be completed and supporting identification documentation verified, or
– including certified copies (Authorised certifiers are outlined on the relevant form) of the supporting identification
documentation with the completed forms you send to us.
u continue to section 2
macquarie.com
Super and Pension Manager II Application form 4 of 35
2
Personal details (mandatory)
Title: Mr Full given name(s): Patrick Peter
Surname: Collins Gender: Male Female

Any other name known by:
Date of birth: 6 / 10 / 1955 Occupation: Bottle Shop Manager
3
Tax file number
If you do not provide your TFN, we are unable to accept contributions made by you or someone on your behalf (other than
your employer). For superannuation accounts being established for a minor, the minor’s TFN must be quoted in order for us
to accept contributions for them.
Tax file number (TFN) or TFN exemption reason: 126 724 773
Please note an exemption reason is not sufficient, in place of a TFN, for us to accept member contributions.
4
Address and contact details (mandatory)
Residential address – failure to provide may delay or prevent account opening (cannot be a PO Box or care of a third party)
Street name and number: 44 Royalist Rd
Suburb: Mosman
State: NSW Postcode: 2088 Country: Australia
Postal address (if different from your residential address)
Street name and number or PO Box:
Suburb:
State: Postcode: Country:
Contact details
Work phone number: 0293169738 Home phone number: 0299040384
Mobile phone number*: 0488196018
Email address*: p.j.collins@bigpond.com
Temporary resident clients

Please cross this box only if you are or have been the holder of a temporary resident visa (other than a ‘retirement’ or ‘investor

retirement’ visa) and are not an Australian citizen or permanent resident, or a New Zealand citizen. From 1 April 2009, the
conditions of release under which you can access your benefits may be restricted. Please refer to your adviser or us for further
information on temporary residents’ conditions of release.
* These fields are mandatory for security purposes.

5
Contact details – child superannuation accounts
If the superannuation account is being established for a minor, details of the child’s parent/guardian or legal personal
representative must be completed in this section. This person must sign this application.
Details of parent or guardian

Title: Full given name(s):
Surname:
Any other name known by: Gender: Male Female

Date of birth: / / Occupation:
Contact details
Work phone number: Home phone number:
Mobile phone number*:
Email address*:
* These fields are mandatory for security purposes.
6
Online access
Do you have an existing Macquarie ID?
No Yes, please specify your Macquarie ID:
If no, we will provide you with a Macquarie ID and online access to your account through Macquarie Online. If you do not check
a box, a new Macquarie ID will be issued to you.
7
Statements and annual report
• We will make available a detailed statement on the value of your account, and any transactions that have taken place as at
30 June (annual statement). We will also prepare a half yearly statement as at 31 December available on Macquarie Online at
macquarie.com.au/personal
• We also prepare an annual report about the management, financial performance and position of the Fund for each financial
year. This is available free of charge from us, at macquarie.com.au/yourwrap or you can receive a hard copy annual report by
contacting us on 1800 025 063.
8
Broker election
Your adviser will be able to buy and sell Australian listed securities via the Wrap website using a nominated broker.
Please refer to the “Authorised broker list”, available from your adviser, for the broker code(s).
If you wish to include additional nominated brokers to trade on your account, please list the institution(s) here.
Broker name: Broker code:

9
Bank account details for withdrawals and/or pension payments
For superannuation accounts, the below details will be the default account details for the payment of withdrawal requests.
For pension accounts, pension payments will be made to this account on or around the 15th day of the month.
Australian financial institution name:
BSB: – Account number:
Account name:
Any amendments to this section must be signed in full by the applicant. This section must be completed for pension accounts.
Superannuation applicants u continue to 10

Pension applicants u go to 14
10
Do you wish to use the direct credit facility?
No u go to section 11
Yes, please select the contribution type (one only):
Personal contributions* Spouse contributions Child contributions (available for applicants under 18 years).
* If you wish to claim a tax deduction for your contribution, we require you to send us a completed Deduction notice for personal contributions available from your
adviser or the NAT 71121 form, available from the Australian Taxation Office website. For more information on your eligibility to claim a deduction, please refer to
the Opening and adding to your account section of the PDS.
11
Beneficiary nomination
Have you included a Non-lapsing death benefit nomination with your application?
Yes u go to section 12 No. If you have an existing valid Non-Lapsing nomination on another Macquarie

Superannuation account which you wish to apply to this new account. Please supply
the existing account number
Please note: if you enter an existing account number here the existing account must have a valid Non-Lapsing Nomination (not a
reversionary pension nomination).
12
Contribution/rollover details (Super Manager II only)
A. Contribution details
Personal contribution: $
DEDUCTION NOTICE (OPTIONAL)

Only complete if you intend to claim a tax deduction for all/part of the above contribution. This will be taken to be a
deduction notice in the ATO approved form and cannot be revoked or withdrawn. Please speak to your adviser for
further information.
For contribution(s) made in the financial year ending: 30 June 20

Amount of personal contribution(s) covered by this Deduction
$
Notice that I intend to claim as a tax deduction:
If you do not make a selection we will assume you do not wish to lodge a deduction notice.
Contribution/rollover details (Super Manager II only) (continued)

Employer superannuation
guarantee (SG) contribution: $ Employer other contribution: $
Employer salary sacrifice contribution: $ Spouse contribution: $
Other contribution: $
Please specify the other contribution type and attach appropriate documentation:
Please cross here if any of these contributions include an in-specie transfer of assets.
Please ensure: • cheques are payable to: MIML Super Manager II (full account name)
• your TFN has been provided in section 3, otherwise we will only accept employer contributions
• non-concessional contributions do not exceed the non-concessional contribution cap, otherwise excess
contribution tax rates may apply (refer to the Taxation section of the Technical Information Booklet (TIB),
available at macquarie.com.au/supertech for more information).
B. A rollover from another fund
Name of institution Account/policy number Cash rollover In-specie rollover
$ $
$ $
$ $
Please cross here if any of these rollovers include an in-specie transfer of assets.
Please ensure: • cheques are payable to: MIML Super Manager II (full account name)
• a Rollover authority is sent to the paying institution (if applicable)
• rollovers are accompanied by a Rollover Benefit Statement, provided by the other fund
• a separate withdrawal form is submitted for rollovers from a self managed super fund with a Macquarie
Cash Management Account or Macquarie Investment account.
C. Rollover from another account within the fund
If you are rolling over from another account within the Fund, please complete the details here. Please note that this
constitutes a request to roll over benefits from your existing account.

Note: If you have an existing Super Manager, Super Manager II, Super Consolidator or Super Consolidator II, you cannot
apply to open a Super Manager II account in addition to your existing Macquarie superannuation account. You are required
to add any rollovers or contributions into your existing Macquarie superannuation account, or close your existing account at
the same time this account is opened.
Existing account details
Account name:
Account number:
Amount to be transferred
Entire balance (your account will be closed)
Partial amount by (select one only)
transferring $ from the above account, or
leaving $ in the above account and transferring the rest.

Specify the assets to be transferred out of or remain in the account (depending on your election) or attach a list:
• Where no list of assets is provided, we will transfer out of the account’s cash hub/account.
• We will draw the tax components proportionally from the components held in your account.
• Please specify which preservation component to transfer over (or the order of preservation components you wish to
transfer over):

• Importantly, you must leave the required minimum balance in the account (refer to the applicable Macquarie PDS for
minimum cash balances).
13
Adviser service fee details (Super Manager II only)
Please note: Macquarie will apply GST net of the effect of any reduced input tax credit to the base fee rate set by
your adviser By completing this section, you authorise the payment to your adviser.
Adviser service fee details

Initial advice fee (ex-GST) (specific dollar amount only): $
Adviser service fee: The adviser service fee is an annual fee,

OR on managed … and
calculated on your daily account valuation and deducted monthly.
On all investments (including Australian listed
Choose one of the following:
investments SMAs) and term deposits securities
(a) or (b) or (c) OR (a) and (c) OR (b) and (c) (ex-GST) % pa (ex-GST) % pa… (ex-GST) % pa
(a) Tiered fee (ex-GST) (percentage of your account balance)
Account balance from Account balance to
$0.00 $
$ $
$ $
$ $
$ $ 999,999,999.99
(b) Flat fee (ex-GST) (percentage of your account balance)
(c) Flat fee structure – dollar fee per annum (ex-GST) $

Ongoing adviser service fees annual indexation (this will apply to all fees above if applicable)
%
Consumer Price Index (CPI) OR Flat percentage
Adviser transaction fees (online purchases only) $ per transaction OR
% of the transaction value (ex-GST)

Any amendments to this section must be signed in full by the applicant.

Superannuation applicants u go to section 18

Pension applicants u complete 14 to 18
14 Pension details
A. What pension type are you applying for?
A transition to retirement pension. I have reached my preservation age but have not permanently retired from
the workforce.1
A standard (account based) pension: I declare I have met one of the conditions of release that allows me full
access to my superannuation or I am rolling over an unrestricted non-preserved amount only.1 Where required,
please supply the relevant documentation to verify you have met a condition of release.1
Death benefit pension. Only select this option if you are rolling over an existing death benefit from another fund.
Note, you cannot combine your existing benefits with a death benefit rollover.2
You must nominate one of the above pension types before we can process your application.
B. Pension payment details

Please nominate your annual pension amount:
M
inimum
Maximum (transition to retirement pensions only). This amount will not be prorated (ie the maximum will be paid over

the remaining period in the financial year)
A specific annual amount of $ over an entire (12 month) financial year

On 1 July, increase my annual pension payments by: Nil T
he inflation rate (CPI)
A specific percentage amount %
Payment frequency: Monthly Quarterly Half-yearly Yearly
First payment month:
If you do not complete any payment details we will assume that you wish to receive the minimum annual pension
amount paid monthly beginning the next available payment with an annual increase of “Nil”.
C. Death benefit pension details

Please complete the following for death benefit pensions.
Name of deceased:
Date of birth: / /
Date of death: / /
Tax file number of deceased:

1 For more information, refer to the Preservation rules section of the TIB, available at macquarie.com.au/supertech
2 For more information, refer to the Taxation section of the TIB, available at macquarie.com.au/supertech
15
Beneficiary nomination
You should update your nomination when commencing a pension. Please note we cannot accept a nomination made by an
attorney or any other agent.
PLEASE COMPLETE EITHER (A) OR (B) BUT NOT BOTH

A. Reversionary pension option
You may make this nomination only when the pension is commenced and there are some circumstances in which a reversionary
pension nomination cannot be revoked. Please speak to your adviser for further information on reversionary nominations.
Title: Full given name(s):
Surname:
Date of birth: / / Gender: Male Female
Street name and number or PO Box:
Suburb:

State: Postcode: Country:
Relationship to you: Spouse Qualifying child1 Interdependent person (who is not a child)
Financially dependent person (who is not a child).
B. Non-lapsing death benefit nomination

You may make this nomination at any time and you may change it at any time.
Have you included a non-lapsing death benefit nomination with your application?
Yes u go to section 16
o. If you have an existing valid Non-Lapsing Nomination on another Macquarie Superannuation account which you
N
wish to apply to this new account, please supply the existing account number:

Please note: if you enter an existing account number here the existing account must have a valid Non-Lapsing
Nomination (not a reversionary pension nomination).
1 A qualifying child is a child who (at the time of the member’s death) is:
• less than age 18, or
• aged 18 to 24 inclusive and is financially dependent on the member, or
• aged 18 or more and has a qualifying disability (broadly, this is a disability that is permanent or likely to be permanent and results in the need for ongoing
support and a substantially reduced capacity for communication, learning or mobility).
16
Contribution/rollover details (Pension Manager II only)
Please note that you must include details of all contributions and rollovers with which you wish to commence this
pension. Any amounts not included below CANNOT be accepted into this pension account. Where an in specie
transfer of assets is used to commence a pension, the assets are not received into the pension account until the
day after they are transferred. Therefore, the value of these assets when the pension commences will generally be
different to the transfer value due to market movements. This should be factored in when commencing a pension to
avoid exceeding the transfer balance cap.
If there is insufficient space below, please include a separate attachment with the details of additional contributions or
rollovers with your application.
A. Contribution details
Personal contribution: $
DEDUCTION NOTICE (OPTIONAL) – You must complete this section if you intend to claim a tax deduction
for all/part of the above contribution. This will be taken to be a deduction notice in the ATO approved form
and cannot be revoked or withdrawn. Please speak to your adviser for further information.

Amount of personal contribution(s) covered by this
$
Deduction Notice that I intend to claim as a tax deduction:
If you do not make a selection we will assume you do not wish to lodge a deduction notice.
Employer superannuation guarantee (SG) contribution: $
Employer other contribution: $
Employer salary sacrifice contribution: $
Spouse contribution: $
Other contribution: $
Please specify the other contribution type and attach appropriate documentation:
Please cross here if any of these contributions include an in-specie transfer of assets.
Please ensure:
• cheques are payable to: MIML Pension Manager II (full account name)
• your TFN has been provided in section 3, otherwise we will only accept employer contributions.
Please note that contributions cannot be made directly to a pension account. We will open a Super Manager II account
to process the contribution and transfer the balance to a Pension Manager II account when the pension is ready to
commence (eg after debiting any contributions tax).
B. A rollover from another fund
Death benefit
Name of institution Account/policy number Cash rollover In-specie rollover rollover
AMP Summit Personal Pension 0097713D301 $ $
AMP Summit Allocated Pension 0097713D302 $ $
Unisuper Accumulation 1 13971194 $ $
Please cross here if any of these rollovers include an in-specie transfer of assets.
Please ensure:
• cheques are payable to: MIML Pension Manager II (full account name)
• a Rollover authority is sent to the paying institution (if applicable)
• rollovers are accompanied by a Rollover Benefit Statement, provided by the other fund
• a separate withdrawal form is submitted for rollovers from a self managed super fund with a Macquarie Cash Management
Account or Macquarie Investment account.
Contribution/rollover details (Pension Manager II only) (continued)

C. Rollover from another account within the fund
If you are rolling over from another account within the Fund, please complete the details here. Please note that this
constitutes a request to roll over benefits from your existing account.
Existing account details
Account name:
Account number:
Amount to be transferred
Entire balance (your account will be closed). If that account holds insurance:
Transfer it to a standalone policy (attach the insurance application)
Cancel my insurance
There is no insurance on the account
Partial amount by (select one only)
transferring $ from the above account, or
leaving $ in the above account and transferring the rest.

Specify the assets to be transferred out of or remain in the account (depending on your election) or attach a list:
• Where no list of assets is provided, we will transfer out of the account’s cash hub/account.
• Importantly, you must leave the required minimum balance in the account (refer to the applicable Macquarie PDS for
minimum balances).
Lodging/varying a deduction notice (optional)
Personal contribution $
Only complete if you intend to claim a tax deduction for all/part of the above contribution. This will be taken to be

a deduction notice in the ATO approved form and cannot be varied once the pension has commenced based in
whole or part on this contribution. Please speak to your adviser for further information.

Amount of personal contribution(s) covered by this
$
Deduction Notice that I intend to claim as a tax deduction:
If you do not make a selection we will assume you do not wish to lodge or vary a deduction notice.
17
Adviser service fee details (Pension Manager II only)
Please note: Macquarie will apply GST net of the effect of any reduced input tax credit to the base fee rate set by
your adviser. By completing this section, you authorise the payment to your adviser of the amounts set out below.
Adviser service fee details

Initial advice fee (ex-GST) (specific dollar amount only): $ 2,500.00
Adviser service fee: The adviser service fee is an annual fee,

calculated daily on your account valuation and deducted monthly. OR on managed … and
Choose one of the following: On all investments (including Australian listed
(a) or (b) or (c) OR (a) and (c) OR (b) and (c) investments SMAs) and term deposits securities
(ex-GST) % pa (ex-GST) % pa… (ex-GST) % pa
(a) Tiered fee (ex-GST) (percentage of your account balance)
Account balance from Account balance to
$0.00 $
$ $
$ $
$ $
$ $ 999,999,999.99
(b) Flat fee structure – dollar fee per annum (ex-GST)) 1.075
(c) Flat fee (ex-GST) (specific dollar amount) $

Ongoing adviser fees annual indexation (this will apply to all fees above if applicable)
Consumer Price Index (CPI) OR Flat percentage %
Adviser transaction fees (online purchases only) $ per transaction OR
% of the transaction value (ex-GST)

Any amendments to this section must be signed in full by the applicant.

18
Declaration and signature
Before you sign this application, Macquarie Investment l) that you have read and understood the Privacy Statement
Management Limited (the Trustee), or your adviser, is contained within the PDS and consent to the collection,
obliged to give you the current Macquarie Super and use and disclosure of your personal information in
Pension Manager II (Super and Pension Manager II) Product accordance with the Privacy Statement (as amended or
Disclosure Statement (PDS) dated 23 November 2019. replaced from time to time), and
This document should be read in conjunction with the m) that if you have selected to open a death benefit pension,
Macquarie Superannuation Technical Information Booklet you are rolling over a death benefit and you are eligible to
(TIB) (available from macquarie.com.au/supertech) and receive a death benefit income stream. You acknowledge
Superannuation Investment Menu (available at macquarie. you cannot combine these benefits with any of your
com.au/supermenu) which together form the PDS, and any existing member benefits.
supplementary PDSs before applying for a Super and Pension
You agree:
Manager II account. The PDS will help you to understand the
product and decide if it is appropriate for your needs. You a) to be bound by the terms and conditions disclosed in
must also consider each PDS and other disclosure documents the Super and Pension Manager II PDS, any document
for an investment option prior to placing your investment and incorporated into the PDS by reference and any
any insurance PDS when applying for insurance through your supplementary PDS
account. This application form must not be used unless it was b) to be bound by the trust deed and rules of the Macquarie
attached to or accompanying the PDS. The PDS is issued Superannuation Plan
by Macquarie Investment Management Limited (MIML, the c) that the Trustee can notify you of a change to the Investment
Trustee) ABN 66 002 867 003 AFSL 237492 RSEL L0001281. Menu by updating the Superannuation Investment Menu
Please note the Trustee has complete discretion whether or available at macquarie.com.au/supermenu, and
not to accept your application. d) that if you take out insurance through your Super account,
By signing below: we are required to cancel your insurance on and after
1 April 2020 if you have an account balance which is less
You confirm:
than $6,000 and on or after 1 November 2019 you have
a) that this application was signed in Australia not had an account balance equal to or greater than $6,000
b) that you have personally received the PDS before or and you have not elected to maintain insurance even if your
at the same time as you received the application form. account balance is less than $6,000. You acknowledge
You have read and understood the current PDS and any that you can maintain your insurance even if your account
supplementary PDSs balance is less than $6,000 by making this election as part
c) that you understand that the PDS has been prepared of your insurance application with the insurer.
without taking into account your objectives, financial situation You acknowledge:
or needs and you should consider the appropriateness of
a) and confirm that you have received, read and understood
the information in the PDS before acting on the information
the offer documents for each of the investments and
d) that you have appointed an adviser and received advice insurance you have selected and understand that you may
from them in relation to your application not have the most up-to-date information and you may
e) that you consent to the Trustee supplying information about not be aware of all material changes about an investment
your portfolio to the adviser named in this application, the when you make additional investments
adviser’s licensee and any authorised staff of the licensee b) that if you have selected an illiquid investment or where
f) that all information provided by you and your adviser in you have selected an investment which becomes illiquid,
connection with this application is complete, true and you understand that the nature of such an investment
correct and you understand that the Trustee is relying on may mean that should you, at a future time, request that
the information in connection with carrying out its various the illiquid part or all of your portfolio be rolled over or
duties and functions transferred, your request may not be able to be processed
within the standard 30 day period
g) that you have read and understood and consent to the
conditions of the tax file number collection, personal c) that any rollover requests detailed in your application
information consents and the telephone recording policy in will be initiated when your application is submitted and
the PDS that you are solely responsible in relation to your other
superannuation fund for the payment of any fees and costs
h) that you will provide the Trustee with all necessary
on exit, withdrawal fees or other charges and notifying
information under the Anti-Money Laundering and
your employer of any changes to the superannuation fund
Counter-Terrorism Financing Act 2006 (Cth) rules and
where employer contributions are to be paid
other subordinate instruments
d) that when a rollover request is effected, your existing
i) that you are eligible to be a member of Super and
insurance arrangements may cease and you may not
Pension Manager II
get the same type of insurance cover through Super and
j) if submitting contributions, that you are eligible to Pension Manager II
contribute based on the eligibility criteria outlined in
e) that if you do not provide the Trustee with information as
the Contributing into superannuation section of the TIB requested, or there is a delay in providing the Trustee with
(available at macquarie.com.au/supertech), or advice this information, you understand that the Trustee may not be
received from your adviser able to open your account. You understand the Trustee is not
k) that any additional action that requires something to be liable for any loss incurred by you as a result of any action of
done by you (eg arranging for rollover amounts to be paid to the Trustee which either delays the account being opened or
the Trustee), you will complete the required action as soon results in this application being declined, when these actions
as possible or as otherwise agreed with the Trustee are necessary for the Trustee to process your application
Declaration and signature (continued)

f) that your interest in any holdings in the Wrap Cash Hub set out in the PDS. You acknowledge that where your
and any term deposits will not be directly protected by the adviser and/or dealer group changes or is removed, such
Federal Government’s Financial Claims Scheme (FCS). payments may change or cease as stated in the PDS,
You understand you may have a pro-rata entitlement to e) the Trustee to update your personal details (including
the Fund’s aggregate cap amount of $250,000 per deposit contact details), where a Government agency notifies us that
account per authorised deposit-taking institution and that
the details we have on record for you are incorrect, and
this entitlement ranks in proportion with all other members’
Wrap Cash Hub and term deposit holdings f) sharing of your Data with third party service providers used
g) that investments in Super and Pension Manager II, by you or your adviser and their Associates as described
other than any holdings in the Wrap Cash Hub and term in the PDS.
deposits with Macquarie Bank Limited, are not deposits You consent to the Trustee communicating with you
with or other liabilities of Macquarie Bank Limited (MBL) electronically by using any email address or mobile telephone
ABN 46 008 583 542 or of any Macquarie Group company, number nominated by you or by making the communication
and are subject to investment risk, including possible or other information available to you using the Macquarie
delays in repayment and loss of income or principal Online accessible from online.macquarie.com.au or any other
invested. You further acknowledge that none of MBL,
website, app or online portal used for Macquarie Wrap in the
Macquarie Investment Management Limited, nor any other
future at a location notified to you or in any other way agreed
investment managers referred to in this PDS, nor any other
with you. Any email address or mobile telephone number
member company of the Macquarie Group guarantees
provided to the Trustee for these purposes should be an email
the performance of Super and Pension Manager II or the
address or mobile telephone number which you access regularly
repayment of capital from Super and Pension Manager II or
and you agree to notify the Trustee promptly if you change this
any particular rate of return of the investments purchased
email address or mobile telephone number. You acknowledge
through Super and Pension Manager II
that it is your responsibility to regularly check your nominated
h) that you can change your marketing preferences by email address and mobile phone or Macquarie Online
telephoning us on 1800 025 063 or visiting accessible from online.macquarie.com.au to access reporting
macquarie.com/optout-bfs and ongoing disclosure in relation to your account.
i) that your existing fund may charge fees or costs on
exiting; please check with them For investors claiming a tax deduction for
j) that moving funds may have taxation, investment and personal contributions
insurance implications; we recommend you consult with You understand the restrictions on lodging or varying your
your adviser, and deduction notice as outlined in the Opening and adding to
k) that you may apply for further products from Macquarie in the your account section in the PDS:
future and the information provided by you in this application • if you have completed the deduction notice sections in the
form, or to your financial adviser, to enable the Macquarie application form, you confirm:
group to comply with its obligations under the US Foreign
–– you are lodging the notice(s) before both of the following
Account Tax Compliance Act (FATCA) and the Common
dates: the day that you lodged your income tax return for
Reporting Standards (CRS) under the Taxation Administration
the year(s) in which the personal contributions covered
Act 1953 (Cth), their supporting regulations and any related
by this notice were made and the end of the income year
laws or official guidance designed to implement those laws
in Australia is correct and where relevant reflects your tax after the year(s) in which the contribution was made,
status. You agree that you will promptly notify and provide –– at the time of completing the notice(s): you intend to
Macquarie with any changes to the information provided by claim the personal contributions stated in the deduction
you in connection with FATCA and CRS and on request with notice as a tax deduction in the year(s) stated; you have
any further information which is necessary or desirable for not included these contributions in an earlier valid notice;
Macquarie to comply with any obligations it may have. and the Fund still holds these contributions, and
You authorise: –– you understand that you cannot vary this notice after a
pension has commenced
a) your adviser and other people working in or for their
organisation (Associates) to provide additional information • if you have completed the deduction notice section after
required to open your account that has not been included having already lodged a notice with the Fund for these
on this form contributions and wish to reduce the amount stated in that
notice, you confirm:
b) your adviser and their Associates to receive and access your
personal information (Data) for the purpose of managing your –– you intend to claim the personal contributions stated in
investment and conducting such transactions you authorise. the deduction notice section as a tax deduction, and
You acknowledge that you need to inform the Trustee of any –– you wish to vary your previous notice for these
change in relation to this authority or your adviser contributions by reducing the amount you advised in
c) the Trustee to follow up any outstanding issues with your your previous notice. You confirm that either: you have
rollover institutions not yet lodged your income tax return for the year stated
d) payments to your financial adviser and/or adviser’s dealer for the contribution and this variation notice is being
group as set out in this application form. You confirm lodged on or before 30 June of the following financial
that these fees relate solely to services relating to the year; or, the Australian Tax Office has disallowed your
provision of superannuation benefits to you and is not part claim for a deduction for the relevant year(s) and this
of an early release scheme. You authorise the Trustee to notice reduces the amount stated in your previous notice
deduct such fees from your Wrap Cash Hub on the terms by the amount that has been disallowed.
Declaration and signature (continued)

For investors signing under power of attorney
If you are signing under power of attorney, you confirm that you have no notice of the revocation of the power of attorney.
For investors who are or have been outside of Australia

The Trustee does not intend this financial product to be marketed directly or indirectly to applicants outside of Australia.
You acknowledge that neither the Trustee nor your financial adviser has marketed or promoted this financial product outside of
Australia to you.
For child contributions

The application is to be signed by the child’s parent or guardian, who acknowledges and declares as follows:
• you accept all responsibility for the decision to make this investment on your child’s/ward’s behalf, and
• you will not hold the Trustee responsible in the event that this investment proves unsuitable for your child/ward.
For investors accessing the PDS online

You have personally received the electronic PDS or a paper printout of the electronic PDS accompanied by or attached to this
application form before or at the same time as you received this application form.
Please note that electronic or digital signatures will not be accepted.
Signature
Date: / /
Title: MR Full given name(s): Patrick Peter
Surname: Collins
If you have not done so already, review the checklist on page 1 and 2 to ensure there are no
delays in opening your account. If you have any further questions about completing this application
please contact your adviser.
Please email your completed application and all accompanying documents to
wrapsolutions@macquarie.com or send them to Macquarie Wrap GPO Box 4045 Sydney
NSW 2001 (please affix a stamp).
IDENTIFICATION FORM
INDIVIDUALS & SOLE TRADERS
GUIDE TO COMPLETING THIS FORM

o Complete one form for each individual. Complete all applicable sections of this form in BLOCK LETTERS.
o Tax information must be collected from the individual
o Contact your licensee if you have any queries.
SECTION 1: PERSONAL DETAILS

Surname Date of Birth dd/mm/yyyy
Collins 06/10/1955
Full Given Name(s)
Patrick Peter
Residential Address (PO Box is NOT acceptable)
Street
44 Royalist Rd
Suburb State Postcode Country
Mosman NSW 2088 Australia
COMPLETE THIS PART IF INDIVIDUAL IS A SOLE TRADER
Full Business Name (if any) ABN (if any)
Principal Place of Business (if any) (PO Box is NOT acceptable)

Street
Suburb State Postcode Country
SECTION 2: TAX INFORMATION

Tax Residency rules differ by country. Whether an individual is tax resident of a particular country is often (but not always) based on the amount of time a person
spends in a country, the location of a person’s residence or place of work. For the US, tax residency can be as a result of citizenship or residency.
Please answer both tax residency questions:
Is the individual a tax resident of Australia? Yes No
Is the individual a tax resident of another Country? Yes No
If the individual is a tax resident of a country other than Australia, please provide their tax identification number (TIN) or equivalent below. If
they are a tax resident of more than one other country, please list all relevant countries below.
A TIN is the number assigned by each country for the purposes of administering tax laws. This is the equivalent of a Tax File Number in Australia or a Social
Security Number in the US. If a TIN is not provided, please list one of the three reasons specified (A, B or C) for not providing a TIN.
1. Country TIN If no TIN, list reason A, B or C
If there are more countries, provide details on a separate sheet and tick this box. .
Reason A The country of tax residency does not issue TINs to tax residents
Reason B The individual has not been issued with a TIN
Reason C The country of tax residency does not require the TIN to be disclosed
19 May 2017 version – Refer to FSC/FPA GUIDANCE - MANAGING AML/CTF AND FATCA/CRS CUSTOMER IDENTIFICATION OBLIGATIONS for conditions of use
Copyright © May 2017 Financial Services Council Limited and Financial Planning Association of Australia Limited
1/2
IDENTIFICATION
IDENTIFICATION
FORM
FORM INDIVIDUALS
INDIVIDUALS
&&SOLE
SOLETRADERS
TRADERS
SECTION
SECTION3:3:VERIFICATION
VERIFICATIONPROCEDURE
PROCEDURE
Verify
Verify individual’s
thethe individual’s fullfull
name;
name; and EITHER
and EITHER their
their
date
date
of of
birth
birth
or or
residential
residential
address.
address.
o o Complete
Complete Part
Part I (or
I (or if the
if the individual
individual does
does notnot
ownown a document
a document from
from Part
Part I, then
I, then complete
complete either
either Part
Part II or
II or III.)III.)
o o Contact
Contact your
your licensee
licensee if the
if the individual
individual is is unable
unable to to provide
provide thethe required
required documents.
documents.
PART
PART I –I –ACCEPTABLE
ACCEPTABLEPRIMARY
PRIMARY PHOTOGRAPHICIDIDDOCUMENTS
PHOTOGRAPHIC DOCUMENTS
Tick
Tick Select
SelectONE
ONEvalid
valid
option
option
from
fromthis
thissection
sectiononly
only
 Australian
AustralianState
State/ Territory
/ Territorydriver’s
driver’slicence
licence
containing
containinga aphotograph
photographofofthe
the
person
person
 Australian
Australianpassport
passport(a(apassport
passportthat
thathas
hasexpired
expiredwithin
withinthe
thepreceding
preceding2 2years
yearsis isacceptable)
acceptable)
 Card
Cardissued
issued
under
undera a
State
State
ororTerritory
Territoryforforthe
the
purpose
purposeofofproving
provinga aperson’s
person’sage
agecontaining
containinga a
photograph
photographofofthe
theperson
person
 Foreign
Foreignpassport
passportoror
similar
similar
travel
travel
document
document
containing
containinga a
photograph
photographand
andthe
the
signature
signatureofof
the
theperson*
person*
PART
PARTII II– –ACCEPTABLE
ACCEPTABLESECONDARY
SECONDARYIDIDDOCUMENTS should
DOCUMENTS– – should
only
only
bebe
completed
completed
if the
if the
individual
individual
does
does
notnot
ownown
a document
a document
from
from
Part I I
Part
Tick
Tick Select
SelectONE
ONEvalid
valid
option
option
from
fromthis
thissection
section
 Australian
Australianbirth
birth
certificate
certificate
 Australian
Australiancitizenship
citizenship
certificate
certificate
 Pension
Pensioncard
cardissued
issuedbybyDepartment
Departmentofof
Human
Human
Services
Services(previously
(previously
known
knownasasCentrelink)
Centrelink)
Tick
Tick AND
ANDONE
ONEvalid
validoption
optionfrom
fromthis
thissection
section
 A Adocument
documentissued
benefits
benefitstoto
the
issuedbyby
the
the
individual
theCommonwealth
individualand
Commonwealthorora aState
andwhich
whichcontains
containsthe
the
Stateoror
Territory
Territorywithin
individual’s
individual’sname
withinthe
nameand
thepreceding
preceding1212
andresidential
residential
address
months
address
monthsthat
thatrecords
recordsthe
theprovision
provisionofoffinancial
financial
A Adocument
documentissued
issuedbyby
the
theAustralian
AustralianTaxation
TaxationOffice
Officewithin
within
the
thepreceding
preceding1212months
monthsthatthatrecords
recordsa adebt
debtpayable
payablebybythe
the
individual
individual
totothe
the
 Commonwealth
Commonwealth(or(orbybythe
theCommonwealth
Commonwealthtotothe the
individual),
individual),which
which contains
containsthe
theindividual’s
individual’sname
nameand and
residential
residential
address.
address.Block
Blockout
outthe
the
TFN
TFN
before
beforescanning,
scanning,copying
copyingoror
storing
storingthis
thisdocument.
document.
 A Adocument
that
documentissued
thataddress
issuedbyby
addressorortoto
that
a alocal
localgovernment
thatperson
person
government
(the
(thedocument
document
body
bodyororutilities
must
must
utilitiesprovider
contain
contain the
providerwithin
withinthe
theindividual’s
thepreceding
individual’sname
preceding3 3
nameand
months
monthswhich
andresidential
residential
whichrecords
address)
address)
recordsthe
theprovision
provision
ofof
services
servicestoto
If Ifunder
underthe
theage
ageofof18,
18,a anotice
notice that:
that:was
wasissued
issuedtotothe
theindividual
individualbybya a school
schoolprincipal
principalwithin
within
the
thepreceding
preceding3 3
months;
months;and and
contains
containsthe
thename
name
 andandresidential
residential address;and
address; andrecords
recordsthe theperiod
periodofoftime
time thatthe
that the individualattended
individual attended thatschool
that school
PART
PART IIIIII– –ACCEPTABLE
ACCEPTABLEFOREIGN
FOREIGN PHOTOGRAPHIC
PHOTOGRAPHIC IDIDDOCUMENTS should
DOCUMENTS– –should only
only bebe completed
completed if the
if the individual
individual does
does notnot
ownown a document
a document from
from I I
Part
Part
Tick
Tick Select
SelectONE
ONEvalid
valid
option
option
from
fromthis
thissection
sectiononly
only
 Foreign
Foreigndriver's
driver'slicence
licence
that
that
contains
containsa aphotograph
photographofofthe
theperson
personinin
whose
whosename
nameit itissued
issuedand
andthe
the
individual’s
individual’sdate
dateofofbirth*
birth*
 National
NationalIDID
card
card
issued
issuedbybya a
foreign
foreigngovernment
governmentcontaining
containinga a
photograph
photographand
anda asignature
signatureofofthe
the
person
person
ininwhose
whosename
namethe
the
card
cardwas
wasissued*
issued*
*Documents
*Documents that
that areare written
written in in a language
a language that
that is is
notnot English
English must
must bebe accompanied
accompanied byby
anan English
English translation
translation prepared
prepared byby
anan accredited
accredited translator.
translator.
IMPORTANTNOTE:
IMPORTANT NOTE:
Either
 Either attacha alegible
attach legiblecertified
certifiedcopy
copyofofthe
theIDIDdocumentation
documentation usedtotoverify
used verifythe
the individual
individual (andany
(and any requiredtranslation)
required translation)OR
OR
 Alternatively,
Alternatively,if ifagreed
agreedbetween
between your
yourlicensee
licenseeand
andthe product
the product
issuer,
issuer,complete
completethe
theRecord
Recordofof
Verification
Verification
Procedure
Procedure
section
section
below
belowand
and
DO
DONOT
NOTattach
attachcopies
copiesofofthe
the
IDIDDocuments
Documents
SECTION
SECTION4:4:RECORD
RECORDOF
OFVERIFICATION
VERIFICATIONPROCEDURE
PROCEDURE
IDIDDOCUMENT
DOCUMENTDETAILS
DETAILS Document
Document11 Document
Document2 2(if(if
required)
required)
Verified
VerifiedFrom
From Original
Original Certified
CertifiedCopy
Copy Original
Original Certified
CertifiedCopy
Copy
Document
Document Issuer
Issuer
IssueDate
Issue Date
Expiry
Expiry Date
Date
Document
DocumentNumber
Number
Accredited
AccreditedEnglish
EnglishTranslation
Translation N/A
N/A Sighted
Sighted N/A
N/A Sighted
Sighted
ByBycompleting
completing and
andsigning
signingthis Record
this Recordofof Verification Procedure
Verification Procedure I declare
I declarethat:
that:
ananidentity
identity
verification
verificationprocedure
procedurehas hasbeen
been completed
completedinin
accordance
accordance with
withthe
theAML/CTF
AML/CTFRules,
Rules,inin
the
the
capacity
capacityofofanan
AFSL
AFSLholder
holderoror
their
theirauthorised
authorised
representative
representativeand and
the
thetax
tax
information
informationprovided
providedis isreasonable
reasonable considering
considering
the
thedocumentation
documentationprovided.
provided.
AFS
AFSLicensee
LicenseeName
Name AFSL
AFSLNo.
No.
Representative/Employee
Representative/ EmployeeName
Name PhoneNo.
Phone No.
Date
Date
Signature
Signature Verification
Verification
Completed
Completed
1919May
May2017
2017
version
version
– Refer
– Refer
to to
FSC/FPA
FSC/FPA
GUIDANCE
GUIDANCE - MANAGING
- MANAGING AML/CTF
AML/CTF ANDANDFATCA/CRS
FATCA/CRS CUSTOMER
CUSTOMER IDENTIFICATION
IDENTIFICATION OBLIGATIONS
OBLIGATIONS
forfor
conditions
conditions
of of
useuse
Copyright
Copyright©©May
May2017 Financial
2017 Services
Financial Council
Services Limited
Council Limitedand Financial
and Planning
Financial Association
Planning of of
Association Australia Limited
Australia Limited
2/22/2
1 of 2
Macquarie Superannuation
Direct debit request
Macquarie Investment Management Limited ABN 66 002 867 003 AFSL 237 492 RSEL L0001281.
This form is to authorise us to debit another financial institution and make one-off or regular payments to your Macquarie
Superannuation account.
Important information
• This form can be used to set up new, cancel or amend existing direct debit details. One-off contributions can also be made by BPAY®,
Cheque or EFT.
• Please note that all employer contributions are required to be made via SuperStream. For more information about SuperStream, please
refer to the Macquarie Super contributions checklist.
1
Personal details
Full given name(s): Patrick Peter
Surname: Collins Account number (if known):
2
Direct debit details
A. Type of request E. Special contributions
New plan Only a one-off contribution can be elected for the below
contribution types. This form will be processed once we have
Amendment to an existing plan
received the applicable ATO form available on the ATO website
Cancel an existing plan at ato.gov.au/forms. The amount on the ATO form provided
must match the amount specified in section 2C of this form.
B. Frequency (contributions will be deducted on, or close to,
Downsizer contribution (when selecting this option you
the 8th day of each month)
must also provide us with the applicable ATO form NAT
One-off contribution, date to be deducted: 75073 (Downsizer contribution into superannuation form)
before this form can be processed)
/ /
Small business CGT concession contribution (if selecting
(if left blank, this will be deducted immediately) this option you must also provide us with the applicable ATO
form NAT 71161 (Capital gains tax cap election form) before
Monthly
this form can be processed)
Quarterly in March, June, September and December Personal injury contribution (if selecting this option you
Half-yearly in June and December must also provide us with the applicable ATO form NAT
71162 (Contributions for personal injury election form)
Annually in June
before this form can be processed)
C. Total amount $ Direct debit contributions will be deposited to your Cash Account/
Hub on the second business day following the deduction.
Minimum amount: $100
D. Contribution type (please select one only or if this is a

special contribution please proceed to Part E)
Personal contribution* Spouse contribution
Child contribution
We recommend you speak with your adviser to find out if you are
eligible to make the above contribution before submitting this form.
* To claim a tax deduction, we require you to complete a Deduction notice for personal contributions available from macquarie.com.au or the NAT 71121 form,
available from the Australian Tax Office website.
® Registered to BPAY Pty Ltd ABN 69 079 137 518.
macquarie.com
Super and Pension
Macquarie ManagerDirect
Superannuation II Application form
debit request 202ofof35
2
3
Australian financial institution details
Australian financial institution name:
BSB: – Account number:
Account name:
4
I/We wish to participate in the Wrap Superannuation (which understand that my/our direct debit will be automatically
consists of Macquarie Super Manager, Macquarie Super cancelled if three direct debit payments are dishonoured
Manager II, Macquarie Super Consolidator, Macquarie Super because of insufficient money within a 12 month period.
Consolidator II and Macquarie Super Accumulator) direct debit Macquarie will give me/us 14 days notice in writing if they
and I/we agree to be bound by the service agreement terms intend to cancel my/our plan. Macquarie will also charge
and conditions. I/We request you, until further notice in writing, the cost of dishonoured direct debits and any loss in
to debit the nominated account with any amount which the price of the units I/we was/were due to buy against
Macquarie Investment Management Limited ABN 66 002 my/our account.
867 003 AFSL 237 492 RSEL L0001281 (User ID 013402) 10. Macquarie may need to pass on details of my/our direct
may debit or charge me/us in connection with my/their debit request to their sponsor bank in BECS to assist with
Superannuation direct debit, through BECS (Bulk Electronic the checking of any incorrect or wrongful debits to my/our
Clearing System). nominated account.
I/We have completed all relevant sections of this form. I/We 11. Where I have elected a special contribution type in
understand and acknowledge that: section 2E, I am eligible and within the required
1. My/Our nominated financial institution may in its absolute timeframe to make this contribution and funds will be
discretion decide the order of priority of payment by it deducted from my account only when the applicable ATO
of any monies pursuant to this request or any authority form has been provided to Macquarie.
or mandate. 12. Macquarie may not process the request if the amount
2. The financial institution may, in its absolute discretion, on the ATO form does not match the amount specified
at any time by notice in writing to me/us, terminate this in section 2C. If the amounts differ, Macquarie will notify
request as to future debits.
me/us and may request me/us to submit a new request.
3. Macquarie may, by prior notice in writing to me/us within
14 days, vary the timing of future debits. This form must be signed by all account holders for the
4. Monthly contributions will be deducted on, or close to, the account being debited to ensure all parties to the account
8th day of each month. Where the 8th day of the month being debited provide their authorisation.
does not fall on a business day and I am/we are uncertain
whether sufficient cleared money will be available to meet Please note that electronic or digital signatures will
the direct debit, I/we will contact the financial institution not be accepted.
directly and ensure that sufficient cleared money is available.
5. I/We can modify or defer this direct debit at any time by
giving Macquarie 14 days notice, in writing. I/We need to Signature 1:
do this by the 24th day of the month for the change that I/
we am/are requesting to take effect in the following month.
6. I/We can stop or cancel this direct debit at any time by Date: / / Title: Mr
giving Macquarie 14 days notice in writing. I/We need to
do this by the 24th day of the month for the cancellation Name: Patrick Peter Collins
to take effect in the following month. Alternatively, I/we can
cancel my/our direct debit by taking all of my money out of
Wrap Superannuation.
7. If at any time I/we feel that a direct debit against my
nominated account is inappropriate or wrong it is my/our
Signature 2:
responsibility to notify Macquarie as soon as possible.
8. Direct debiting through BECS is not available on all accounts.
I/We can check my account details against a recent Date: / / Title:
statement or check with the financial institution as to whether
I/we can request a direct debit from my/our account. Name:
9. It is my/our responsibility to ensure that there is sufficient
cleared money in my/our nominated account to honour
the direct debit request (DDR) for my/our direct debit. I/We
Please complete and return the form via email to wrapsolutions@macquarie.com or by post
to Macquarie Wrap, GPO Box 4045, Sydney, NSW 2001. If you have any queries about
completing this form please contact your adviser or us on 1800 025 063.
MWS0299 09/19
11ofof20
4
Macquarie Wrap Super

Rollover authority
Macquarie Investment Management Limited ABN 66 002 867 003 AFSL 237492 RSEL L0001281.
Use this form to roll your superannuation benefits via SuperStream into your Macquarie Wrap Superannuation account.
• Do not cancel any existing insurance cover until your application for insurance has been assessed and accepted by the insurer. If you do not
want your current insurance cover cancelled, do not complete this rollover authority.
• Ensure that your existing investment is clearly detailed below for the institution from which you are transferring.
• You do not need to complete this form if you are transferring from another account within the Macquarie Superannuation Plan.
• Rolling over your super benefit to Macquarie may limit your ability to lodge or vary a deduction notice for personal contributions made to the
fund from which you are transferring.
• If you have multiple accounts, please complete a separate form for each account you wish to transfer.
• Please complete, sign and return this request to Macquarie.
1
Rollover details
Please contact your existing superannuation provider to confirm if they have any additional requirements before they can
action this rollover authority. Please complete all details and ensure that you provide us with a valid Australian Business
Number (ABN) and Unique Superannuation Identifier (USI). Any missing information may delay processing of your rollover.
To (paying institution): Australian Super
Street name and number: GPO Box 1901
Suburb: Melbourne State: VIC Postcode: 3001
Phone number (paying institution): 1800331685
Account/membership/policy number: 714476634
Account/membership/policy name: Patrick Peter Collins
ABN: 65714394898 USI: STA0100AU
Is the source of this rollover a complying income stream?

(Term Allocated Pension Manager only) Yes No
Does this rollover contain a death benefit? Yes No

Note: you cannot combine your existing benefits with a death benefit rollover.
Amount to be transferred: Entire balance (your account will be closed)
If partial amount, please specify*: $ 9,503.00
Macquarie account receiving the transfer: Macquarie Super Manager (USI – 65508799106031)
Macquarie Pension Manager (USI – 65508799106032)
Macquarie Super Manager II (USI – 65508799106185)
Macquarie Pension Manager II (USI – 65508799106186)
Macquarie Super Consolidator (USI – 65508799106172)
Macquarie Pension Consolidator (USI – 65508799106173)
Macquarie Super Consolidator II (USI – 65508799106172)
Macquarie Pension Consolidator II (USI – 65508799106173)
Macquarie Term Allocated Pension Manager (USI – 65508799106088)
Macquarie Super Accumulator (USI – 65508799106041)
* Any amendments to this section must be signed in full.
macquarie.com
Super and Pension
Macquarie Manager
Wrap Super II Application
Rollover authority form 222ofof35
4
2
Personal details
Surname: Account number:
Gender: Male Female Date of birth: 6 / 10 / 1955
Postal address
Street number and name or PO Box: 44 Royalist Rd
Suburb: Mosman State: NSW Postcode: 2088
Residential address (leave blank if the same as your mailing address)
Street name and number:
Suburb: State: Postcode:
If your personal details have changed, you may need to contact your existing superannuation provider and update their
records before they action this authority.
3
Cheque details
Required when an electronic rollover payment is not being made by the paying superannuation fund.
Please forward the cheque for the Transfer, this original completed form and any other relevant documentation to:
Macquarie Super GPO Box 4045 Sydney NSW 2001
The following address Name:
Address:
Cheque should be made payable to: MIML – S&PM/S&PM II/S&PC/S&PC II/SA (client name)
4
Proof of identity (optional)
Your existing superannuation provider may require The following can certify copies of the originals as true and
documentation with this transfer request to prove correct copies:
you are the person to whom the superannuation • a permanent employee of Australia Post with five or more years
entitlements belong. We encourage you to contact your of continuous service
existing superannuation provider to determine what • a finance company officer with five or more years of continuous
documentation is required. service (with one or more finance companies)
I have attached a certified copy of my driver’s licence • an officer with, or authorised representative of, a holder of an
or passport or other documentation required by the Australian Financial Services Licence (AFSL), having five or
transferring institution. more years continuous service with one or more licensees
• a notary public officer
Certification of personal document requirements
• a police officer
All copied pages of ORIGINAL proof of identification
• a registrar or deputy registrar of a court
documents (including any linking documents) need to be
• a Justice of the Peace
certified as true copies by any individual approved to do so.
The person who is authorised to certify documents must sight • a person enrolled on the roll of a State or Territory Supreme
the original and the copy and make sure both documents are Court or the High Court of Australia, as a legal practitioner
identical, then make sure all pages have been certified as true • an Australian consular officer or an Australian diplomatic officer
copies by writing or stamping ‘certified true copy’ followed by • a judge of a court
their signature, printed name, qualification (eg Justice of the • a magistrate, or a Chief Executive Officer of a
Peace, Australia Post employee, etc) and date. Commonwealth court.
Super and Pension
Macquarie Manager
4
5
I hereby request that the rollover institution named above complete the transfer of benefits from my account/policy to Macquarie
Investment Management Limited (MIML) ABN 66 002 867 003 AFSL 237 492 as trustee of the Macquarie Superannuation Plan
(SFN 266 912 946, ABN 65 508 799 106), a superannuation fund established to comply with the requirements of the
Superannuation Industry (Supervision) Act. By giving this authorisation to transfer my benefits:
• I hereby give the rollover institution named above authority to provide any and all relevant information to MIML.
• I discharge the trustee of the paying fund from any further liability in respect of the superannuation benefits transferred
to MIML.
• I am aware that I may ask the trustee of my previous fund for information to understand any benefit entitlements that I may
have, including information about any fees or charges that may apply to the rollover, or information about the effect of the
rollover on any benefit entitlements I may have, and I do not require any further information.
• I authorise the deduction of any withdrawal and/or termination fees that may be applicable as a result of the transfer.
Signature
Date: / /
Name: Patrick Peter Collins

Macquarie
MacquarieInvestment
Investment Management Limited
Management Limited
ABN
ABN66
66002
002867
867003
003AFSL
AFSL237
237492
492RSEL
RSELL0001281
L0001281
Macquarie
MacquarieSuperannuation
SuperannuationPlan
PlanABN
ABN6565508
508799
799106
106RSE
RSER1004496
R1004496
11Shelley
ShelleyStreet
Street Telephone Telephone 1800 025 063
1800 025 063
Sydney
SydneyNSWNSW2000
2000 Facsimile Facsimile 1800 025 175
1800 025 175
GPO
GPOBoxBox4045
4045
SydneyNSW
Sydney NSW2001
2001
Offices also in Melbourne, Brisbane, Perth, Adelaide, Auckland (NZ)
1 November
23 April 2014 2019
TO WHOM IT MAY CONCERN

TO WHOM IT MAY CONCERN SPIN USI
Macquarie
Re: Super Manager MAQ0157AU 65508799106031
Macquarie Super Manager (MAQ0157AU)
Macquarie Pension Manager
Macquarie MAQ0158AU
Allocated Pension Manager 65508799106032
(MAQ0158AU)
Macquarie
Macquarie
Macquarie
Macquarie
Term Pension
Term Allocated Allocated Pension MAQ0355AU
Manager
SuperIIConsolidator (MAQ0779AU)
Super Manager
Macquarie Pension Consolidator (MAQ0780AU)
Macquarie Pension Manager II
)
65508799106088SFN 266 912 946
Manager (MAQ0355AU)
65508799106 18ABN
65508799106186
5 65 508 799 106
SFN 266 912 946
Macquarie Super Accumulator (MAQ0311AU)
Macquarie Super Consolidator MAQ0779AU 65508799106172 ABN 65 508 799 106
Macquarie Pension
In reference Consolidator
the above superannuation fund, MAQ0780AU
I confirm that: 65508799106173
Macquarie Super Consolidator
1. The trustee of the FundII is an approved trustee by the Australian
65508799106172
Prudential Regulation
Authority
Macquarie under
Pension the Superannuation
Consolidator II Industry (Supervision) Act 1993 (SIS).
65508799106173
2. The Fund
Macquarie SuperisAccumulator
a regulated superannuationMAQ0311AU
plan for the purposes of SIS.
65508799106041
3. It is the intention of the trustee that the Fund will be administered so that it will be taxed as a
complying
In reference superannuation
to the fund. fund, I confirm that:
above superannuation
4. The trust deed of the Fund allows benefits
1. the trustee of the Fund is an approved to the
trustee by be transferred to the Fund
Australian Prudential and the Authority
Regulation Fund can
accept and hold preserved benefits in the manner prescribed
under the Superannuation Industry (Supervision) Act 1993 (SIS) under SIS.
5. The trust deed of Fund allows the Fund to accept contributions, including employer contributions.
2. the Fund is a regulated superannuation fund for the purposes of SIS
6.it isPlease
3. mail cheques
the intention and paperwork
of the trustee to: will be administered so that it will be taxed as a
that the Fund
Macquarie Wrap
complying superannuation fund
GPO Box 4045
4. the trust deed of the Fund allows benefits to be transferred to the Fund and the Fund can accept
Sydney NSW 2001
and hold preserved benefits in the manner prescribed under SIS
5. the trust deed of Fund allows the Fund to accept contributions, including employer contributions.
Yours faithfully
Yours faithfully
Andrew Wood
Division Director, Macquarie Adviser Services
Stephen Asplin
Division Director, Macquarie Banking and Financial Services
MWS0045 10/19
11ofof20
4

Rollover authority
1
Rollover details
To (paying institution): AMP Summit Personal Super
Account/membership/policy number: 0097713D201
Account/membership/policy name: Patrick Collins
ABN: 92381911598 USI: NMM0104AU


If partial amount, please specify*: $
macquarie.com
Super and Pension
Macquarie Manager
4
2
Personal details
Surname: Collins Account number:
Postal address
3
Cheque details
Address:
4
Super and Pension
Macquarie Manager
4
5
to MIML.
Signature
Date: / /

Macquarie
MacquarieInvestment
Management Limited
ABN66
ABN 66002
002867
867003
003AFSL
AFSL237
237492
492RSEL
RSEL L0001281
L0001281
Macquarie SuperannuationPlan
PlanABN
ABN6565508
508799
799106
106RSE
RSE R1004496
R1004496
11Shelley
ShelleyStreet
Street Telephone Telephone
1800 025 063
1800 025 063
SydneyNSW
Sydney NSW2000
2000 Facsimile Facsimile
1800 025 175
1800 025 175
GPOBox
GPO Box4045
4045
SydneyNSW
Sydney NSW2001
2001
1 November
23 April 2014 2019

Macquarie
)
Macquarie MAQ0158AU
(MAQ0158AU)
Macquarie
Macquarie Term Pension
Manager 65508799106088SFN 266 912 946
Manager (MAQ0355AU)
Macquarie
Macquarie SuperIIConsolidator (MAQ0779AU)
Super Manager 65508799106 18ABN
5 65 508 799 106
Macquarie Pension Manager II 65508799106186 SFN 266 912 946
Macquarie Pension
65508799106172
Authority
Macquarie under
65508799106173
2. The Fund
65508799106041
complying
Regulation Fund can
6.it isPlease
3. mail cheques
that the Fund
Macquarie Wrap
GPO Box 4045
Sydney NSW 2001
Yours faithfully
Yours faithfully
Andrew Wood
Stephen Asplin
MWS0045 10/19
11ofof20
4

Rollover authority
1
Rollover details
To (paying institution): UniSuper
Street name and number: Level 1, 385 Bourke Street
ABN: 91385943850 USI: 91385943850001


macquarie.com
Super and Pension
Macquarie Manager
4
2
Personal details
Postal address
3
Cheque details
Address:
4
Super and Pension
Macquarie Manager
4
5
to MIML.
Signature
Date: / /

Macquarie
MacquarieInvestment
Management Limited
ABN66
ABN 66002
002867
867003
003AFSL
AFSL237
237492
492RSEL
RSEL L0001281
L0001281
Macquarie SuperannuationPlan
PlanABN
ABN6565508
508799
799106
106RSE
RSE R1004496
R1004496
11Shelley
ShelleyStreet
Street Telephone Telephone
1800 025 063
1800 025 063
SydneyNSW
Sydney NSW2000
2000 Facsimile Facsimile
1800 025 175
1800 025 175
GPOBox
GPO Box4045
4045
SydneyNSW
Sydney NSW2001
2001
1 November
23 April 2014 2019

Macquarie
)
Macquarie MAQ0158AU
(MAQ0158AU)
Macquarie
Macquarie Term Pension
Manager 65508799106088SFN 266 912 946
Manager (MAQ0355AU)
Macquarie
Macquarie SuperIIConsolidator (MAQ0779AU)
Super Manager 65508799106 18ABN
5 65 508 799 106
Macquarie Pension Manager II 65508799106186 SFN 266 912 946
Macquarie Pension
65508799106172
Authority
Macquarie under
65508799106173
2. The Fund
65508799106041
complying
Regulation Fund can
6.it isPlease
3. mail cheques
that the Fund
Macquarie Wrap
GPO Box 4045
Sydney NSW 2001
Yours faithfully
Yours faithfully
Andrew Wood
Stephen Asplin
MWS0045 10/19
11ofof20
4

Rollover authority
1
Rollover details
To (paying institution): Australian Super
ABN: 65714394898 USI: STA0100AU


If partial amount, please specify*: $ 9,503.00
macquarie.com
Super and Pension
Macquarie Manager
4
2
Personal details
Surname: Account number:
Postal address
3
Cheque details
Address:
4
Super and Pension
Macquarie Manager
4
5
to MIML.
Signature
Date: / /

Macquarie
MacquarieInvestment
Management Limited
ABN
ABN66
66002
002867
867003
003AFSL
AFSL237
237492
492RSEL
RSELL0001281
L0001281
Macquarie
SuperannuationPlan
PlanABN
ABN6565508
508799
799106
106RSE
RSER1004496
R1004496
11Shelley
ShelleyStreet
1800 025 063
Sydney
SydneyNSWNSW2000
1800 025 175
GPO
GPOBoxBox4045
4045
SydneyNSW
Sydney NSW2001
2001
1 November
23 April 2014 2019

Macquarie
Macquarie MAQ0158AU
(MAQ0158AU)
Macquarie
Macquarie
Macquarie
Macquarie
Term Pension
Manager
Super Manager
)
65508799106088SFN 266 912 946
Manager (MAQ0355AU)
65508799106 18ABN
65508799106186
5 65 508 799 106
SFN 266 912 946
Macquarie Pension
65508799106172
Authority
Macquarie under
65508799106173
2. The Fund
65508799106041
complying
Regulation Fund can
6.it isPlease
3. mail cheques
that the Fund
Macquarie Wrap
GPO Box 4045
Sydney NSW 2001
Yours faithfully
Yours faithfully
Andrew Wood
Stephen Asplin
MWS0045 10/19
11ofof20
4

Rollover authority
1
Rollover details
To (paying institution): AMP Summit Personal Super
Account/membership/policy number: 0097713D201
Account/membership/policy name: Patrick Collins
ABN: 92381911598 USI: NMM0104AU


macquarie.com
Super and Pension
Macquarie Manager
4
2
Personal details
Postal address
3
Cheque details
Address:
4
Super and Pension
Macquarie Manager
4
5
to MIML.
Signature
Date: / /

Macquarie
MacquarieInvestment
Management Limited
ABN
ABN66
66002
002867
867003
003AFSL
AFSL237
237492
492RSEL
RSELL0001281
L0001281
Macquarie
SuperannuationPlan
PlanABN
ABN6565508
508799
799106
106RSE
RSER1004496
R1004496
11Shelley
ShelleyStreet
1800 025 063
Sydney
SydneyNSWNSW2000
1800 025 175
GPO
GPOBoxBox4045
4045
SydneyNSW
Sydney NSW2001
2001
1 November
23 April 2014 2019

Macquarie
Macquarie MAQ0158AU
(MAQ0158AU)
Macquarie
Macquarie
Macquarie
Macquarie
Term Pension
Manager
Super Manager
)
65508799106088SFN 266 912 946
Manager (MAQ0355AU)
65508799106 18ABN
65508799106186
5 65 508 799 106
SFN 266 912 946
Macquarie Pension
65508799106172
Authority
Macquarie under
65508799106173
2. The Fund
65508799106041
complying
Regulation Fund can
6.it isPlease
3. mail cheques
that the Fund
Macquarie Wrap
GPO Box 4045
Sydney NSW 2001
Yours faithfully
Yours faithfully
Andrew Wood
Stephen Asplin
MWS0045 10/19
Macquarie Superannuation
Non-lapsing death benefit nomination
Use this form to nominate a beneficiary for your superannuation benefits to be paid upon your death.
Before you make a nomination remember: You can nominate your legal personal representative and/or one or more of your dependants as
defined under superannuation law. Nominations are only valid if the person(s) selected below are eligible at the time of death of the member.
If no valid nomination is made Macquarie will pay your benefit to your Legal Personal Representative as outlined in the Product Disclosure
Statement (PDS).
Important: If you submit this form electronically, please allow two business days for your request to be assessed by the trustee, and if
approved your beneficiary details updated.
Please use black ink and print in CAPITALS. Mark boxes with an [] where applicable.
1
Personal details
Account number:
Full name: Patrick Peter Collins

If you have more than one account held in the Macquarie Superannuation Plan, please list the account numbers that this
nomination applies to below. If you do not specify any accounts, your nomination will apply only to the account nominated above,
or to the account opened from the application that this form is attached to.
This nomination is to apply to all my existing Macquarie Super and Pension accounts, or
This nomination applies to the accounts listed below:
2
Nomination
IMPORTANT – BEFORE YOU COMPLETE THIS SECTION: To establish a valid nomination ensure no alterations are made on
this form. Please ensure the death benefits total 100%.
Upon my death I direct Macquarie Investment Management Limited (MIML) in its capacity as trustee of the Macquarie
Superannuation Plan to distribute my account balance as follows:
Nominee 1 full name: LEGAL PERSONAL REPRESENTATIVE (YOUR ESTATE)
Share of death benefit: %
• If you have nominated 100% of the benefit allocation to your Legal Personal Representative in the Share of death benefit
box above, do not complete any further nominations  go to section 3
• If you choose not to nominate your Legal Personal Representative (your estate), please specify 0% in the Share of death
benefit box above and complete the following nominee details below
Nominee 2 full name:
Nominee’s relationship to you: Spouse Child Interdependant* Financial dependant Gender: Male Female
Date of birth: / / Is a child pension required? Yes No Share of death benefit: %
macquarie.com
Super and Pension
Macquarie ManagerNon-lapsing
Superannuation II Application formbenefit nomination
death 342ofof35
2
Nomination (continued)
Unless a child pension has been specified your death benefit will be paid in a form Total death benefits: 100 %
determined by MIML after your death and having consulted your beneficiaries.
Where one or more child pensions are specified please also complete a child
pension schedule, available from your adviser or macquarie.com.au
If you have insufficient room to list all beneficiaries, please complete an additional Non-lapsing death benefit nomination
form and attach to this form.
* Two persons (whether or not related by family) have an interdependency relationship if:
a) they have a close personal relationship, and b) they live together, and c) one or each of them provides the other with financial support, and d) one or each of
them provides the other with domestic support and personal care.
If two persons (whether or not related by family) satisfy the requirement of (a); and they do not satisfy the other requirements of an interdependency relationship
above; and the reason they do not satisfy the other requirements is that either or both suffer from a physical, intellectual or psychiatric disability; they have an
interdependency relationship.
3
Declaration
form to Macquarie via electronic means and will provide to
• Amendments to your nomination cannot be accepted
Macquarie upon request.
(in the event of an error please complete a new form).
• In section 2, the total death benefit must total 100%. • I acknowledge that if my nomination specifies one or more
• This form must be signed by the member and both child pensions on behalf of my children that my nomination
witnesses at the same time. cannot be accepted by the trustee until a child pension
• This form cannot be signed under Power of Attorney schedule is also completed for each child that I have
nominated to receive a child pension.
• I understand that this nomination will be binding on the trustee
Please note that electronic or digital signatures will
if the trustee consents to it and will be valid until they consent not be accepted.
to a valid change of nomination from me.
• I understand this nomination replaces any previous
Signature:
nomination/s provided by me to the trustee.
• I understand that if I have revoked a previous nomination and
wish to make a new nomination in the future, I will need to Declaration date: / / Title: MR
complete a new form.
• I agree to retain the original form if I am submitting this Name: Patrick Peter Collins
Your signature must be witnessed by two people, each of whom is 18 years or older and is not named as a nominee on
the form.
Before me, on the date indicated above as the Declaration Date. Before me, on the date indicated above as the Declaration Date.
Signature of first witness (in black ink) Signature of second witness (in black ink)
Title: Title:
Name: Name:
CHECKLIST: To ensure that your non-lapsing death benefit nomination is processed correctly, please complete the checklist below.
Please ensure you have:
your two witnesses’ completed details and signatures
completed all of your personal details and your beneficiaries’ details
completed a child pension schedule (available from your adviser),
signed and dated the declaration if you have nominated a child pension in section 2.
Please complete and return the form to Macquarie Wrap, GPO Box 4045, Sydney NSW 2001, or via email to
wrapsolutions@macquarie.com. If you have any queries about completing this form please contact your adviser or
us on 1800 025 063.
MWS0036 10/19
Tax file number declaration 35 of 35
This declaration is NOT an application for a tax file number.
■■ Use a black or blue pen and print clearly in BLOCK LETTERS.
■■ Print X in the appropriate boxes.
ato.gov.au ■■ Read all the instructions including the privacy statement before you complete this declaration.
Section A: To be completed by the PAYEE Day Month Year
1 What is your tax 5 What is your date of birth? 0 6 1 0

file number (TFN)? 1 2 6 7 2 4 7 7 3
OR I have made a separate application/enquiry to 6 On what basis are you paid? (select only one)
For more the ATO for a new or existing TFN. Superannuation
Full‑time Part‑time Labour Casual
information, see or annuity
employment employment hire employment
question 1 on page 2 OR I am claiming an exemption because I am under income stream
of the instructions. 18 years of age and do not earn enough to pay tax.
7 Are you: (select only one)
OR I am claiming an exemption because I am in An Australian resident A foreign resident A working
receipt of a pension, benefit or allowance. for tax purposes for tax purposes OR holiday maker
2 What is your name? Title: Mr Mrs Miss Ms 8 Do you want to claim the tax-free threshold from this payer?
Surname or family name Only claim the tax‑free threshold from one payer at a time, unless your
total income from all sources for the financial year will be less than the
C O L L I N S tax‑free threshold.
Answer no here if you are a foreign resident or working holiday
First given name Yes No maker, except if you are a foreign resident in receipt of an
P A T R I C K P E T E R Australian Government pension or allowance.
Other given names 9 (a) Do you have a Higher Education Loan Program (HELP), Student Start-up
Loan (SSL) or Trade Support Loan (TSL) debt?
Your payer will withhold additional amounts to cover any compulsory
Yes repayment that may be raised on your notice of assessment. No
3 What is your home address in Australia?
(b) Do you have a Financial Supplement debt?
4 4 R O Y A L I S T R D Your payer will withhold additional amounts to cover any compulsory
Yes repayment that may be raised on your notice of assessment. No
DECLARATION by payee: I declare that the information I have given is true and correct.
Suburb/town/locality Signature
M O S M A N Date
Day Month Year
State/territory Postcode
You MUST SIGN here
N S W 2 0 8 8
There are penalties for deliberately making a false or misleading statement.
4 If you have changed your name since you last dealt with the ATO,
provide your previous family name.
Once section A is completed and signed, give it to your payer to complete section B.
Section B: To be completed by the PAYER (if you are not lodging online)
1 What is your Australian business number (ABN) or Branch number 5 What is your primary e-mail address?
withholding payer number? (if applicable)
W R A P S O L U T I O N S @
6 5 5 0 8 7 9 9 1 0 6 0 0 1
2 If you don’t have an ABN or withholding M A C Q U A R I E . C O M
payer number, have you applied for one? Yes No
6 Who is your contact person?
3 What is your legal name or registered business name
(or your individual name if not in business)? C L I E N T S E R V I C E S
M A C Q U A R I E Business phone number 1 8 0 0 0 2 5 0 6 3
S U P E R A N N U A T I O N
7 If you no longer make payments to this payee, print X in this box.
DECLARATION by payer: I declare that the information I have given is true and correct.
Signature of payer
4 What is your business address? Date
Day Month Year
G P O B O X 4 0 4 5
There are penalties for deliberately making a false or misleading statement.

Suburb/town/locality
S Y D N E Y Return the completed original ATO copy to: IMPORTANT
State/territory Postcode Australian Taxation Office See next page for:
PO Box 9004 ■■ payer obligations
N S W 2 0 0 1 PENRITH NSW 2740 ■■ lodging online.
Print form Save form Reset form

Sensitive (when completed)
30920917
NAT 3092-09.2017 [JS 39383]
Contacts
Contacts
New South Wales South Australia

1 Shelley Street Level 4, 63 Pirie Street
Sydney NSW 2000 Adelaide SA 5000
Macquarie Investment Management Limited Macquarie Investment Management Limited
GPO Box 4045 GPO Box 2632
Sydney NSW 2001 Adelaide SA 5001
Victoria Western Australia

Level 24, 101 Collins Street Level 23, 240 St George’s Terrace
Melbourne VIC 3000 Perth WA 6000
Macquarie Investment Management Limited Macquarie Investment Management Limited
GPO Box 5435CC PO Box 7306
Melbourne VIC 3001 Cloisters Square
Perth WA 6850
Queensland
Level 8, 825 Ann Street
Fortitude Valley QLD 4006
Macquarie Investment Management Limited
GPO Box 1459
Brisbane QLD 4001
To contact Macquarie, financial advisers please call 1800 025 063.

Existing investors, where you have an adviser, they should be your main point of
contact for your account, so if you have any queries about your account, please talk to
your financial adviser.
Macquarie can also be contacted at Macquarie Wrap GPO Box 4045 Sydney NSW 2001
or by visiting Macquarie Online at macquarie.com.au/personal
63
BFS0207 11/19

Macquarie Pension Manager II Application Form - Collins, Patrick - 19122019 PDF

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3 of 35

Super and Pension Manager II

Superannuation applicants u complete 1 to 13, then 18

Dealer name: Australian Financial Planning Group Dealer code: 7959

Contact number: 0282687000 Email: admin@afpg.com.au

Surname: Collins Gender: Male Female

Date of birth: 6 / 10 / 1955 Occupation: Bottle Shop Manager

Street name and number: 44 Royalist Rd

State: NSW Postcode: 2088 Country: Australia

Postal address (if different from your residential address)

Street name and number or PO Box:

State: Postcode: Country:

Mobile phone number*: 0488196018

Email address*: p.j.collins@bigpond.com

Temporary resident clients

* These fields are mandatory for security purposes.

Details of parent or guardian

Any other name known by: Gender: Male Female

Mobile phone number*:

* These fields are mandatory for security purposes.

Broker name:  Broker code:

Broker name:  Broker code:

Broker name:  Broker code:

Australian financial institution name:

BSB: – Account number:

Superannuation applicants u continue to 10

DEDUCTION NOTICE (OPTIONAL)

For contribution(s) made in the financial year ending: 30 June 20

Contribution/rollover details (Super Manager II only) (continued)

Employer salary sacrifice contribution: $ Spouse contribution: $

Name of institution Account/policy number Cash rollover In-specie rollover

leaving $ in the above account and transferring the rest.

Adviser service fee details

Adviser service fee: The adviser service fee is an annual fee,

(a) Tiered fee (ex-GST) (percentage of your account balance)

Account balance from Account balance to

(b) Flat fee (ex-GST) (percentage of your account balance)

(c) Flat fee structure – dollar fee per annum (ex-GST) $

Adviser transaction fees (online purchases only) $ per transaction OR

% of the transaction value (ex-GST)

Any amendments to this section must be signed in full by the applicant.

Superannuation applicants u go to section 18

B. Pension payment details

A specific annual amount of $ over an entire (12 month) financial year

Payment frequency: Monthly Quarterly Half-yearly Yearly

First payment month:

C. Death benefit pension details

Tax file number of deceased:

PLEASE COMPLETE EITHER (A) OR (B) BUT NOT BOTH

Title:  Full given name(s):

Date of birth: / / Gender: Male Female

Street name and number or PO Box:

B. Non-lapsing death benefit nomination

For contribution(s) made in the financial year ending: 30 June 20

Employer superannuation guarantee (SG) contribution: $

Employer other contribution: $

Employer salary sacrifice contribution: $

B. A rollover from another fund

AMP Summit Allocated Pension 0097713D302 $ $

Unisuper Accumulation 1 13971194 $ $

Contribution/rollover details (Pension Manager II only) (continued)

Partial amount by (select one only)

transferring $ from the above account, or

Date of birth: 6 / 10 / 1955 Occupation: Bottle Shop Manager

Broker name: Broker code:

Broker name: Broker code:

Broker name: Broker code:

Title: Full given name(s):

Consumer Price Index (CPI) OR Flat percentage %

Declaration and signature (continued)

Declaration and signature (continued)